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Public Health Nursing Documentation Guidelines - Indian Health ...

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<strong>Documentation</strong> and Coding <strong>Guidelines</strong> for <strong>Public</strong> <strong>Health</strong> Nurses<br />

Menu Technical Information Description Functionality<br />

• AUT v98.1 through<br />

patch 15<br />

• AUPN v 99.1<br />

through Patch 15<br />

plication ensures that<br />

the most accurate<br />

patient data possible is<br />

maintained. The application<br />

provides a<br />

complete, accurate,<br />

and current patient<br />

profile to assist in evaluation,<br />

tracking, and<br />

billing of care provided.<br />

the patient database<br />

but need viewing access<br />

to the information<br />

contained in the patient’s<br />

online record.<br />

The View Patient’s Registration<br />

Data option<br />

contains and presents<br />

all pertinent information<br />

on registered<br />

patients. The screens<br />

available through this<br />

option are identical to<br />

the screens available<br />

for edit, aside from the<br />

lack of editing capabilities<br />

in the view option.<br />

Electronic <strong>Health</strong> Record<br />

(EHR)<br />

The EHR represents a<br />

novel approach to<br />

electronic health records.<br />

Built on the<br />

VueCentric® Framework,<br />

the EHR is a highly<br />

customizable window<br />

into a patient’s<br />

health record. Because<br />

of its flexibility, the EHR<br />

can be tailored to<br />

meet the needs of a<br />

wide range of user<br />

roles: providers, nurses,<br />

pharmacists, clerks,<br />

and others. Because<br />

the exact layout and<br />

configuration of the<br />

EHR will vary among<br />

user roles and health<br />

care facilities, the<br />

components available<br />

to a given user will also<br />

vary.<br />

The RPMS-EHR is comprised<br />

of multiple functional<br />

components<br />

built upon an open<br />

architecture framework<br />

known as<br />

VueCentric. The<br />

unique construction of<br />

the application from<br />

over 70 discrete components<br />

dictates a<br />

slightly different structure<br />

for technical documentation.<br />

All PHN<br />

users need access to<br />

functions that relate to<br />

documentation of patient<br />

care. Directors of<br />

PHN need an additional<br />

key to allow<br />

them to track and<br />

manage consults.<br />

Referred Care Information<br />

System (BMC)<br />

System Requirements<br />

• Referred Care Info<br />

System (RCIS) v3.0<br />

• First-time RCIS install<br />

doesn’t require<br />

v3.0<br />

The Referred Care Information<br />

System<br />

(RCIS) is a group of<br />

computer programs<br />

that automate the<br />

clinical and administra-<br />

The RCIS provides a<br />

standard tool for automating<br />

the referral<br />

process and maintaining<br />

records on referred<br />

care services. There<br />

<strong>Indian</strong> <strong>Health</strong> Service Page 3-6

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